Confidential Emergency Health Information
Alert to Parents: If your child has a potential life-threatening health
condition (severe bee sting allergy, food allergy, severe asthma, Epi-Pen,
Diabetes, severe seizures, etc), the Alabama Board of Nursing requires the
school nurse to have on file a medication or treatment order and a Nursing
Plan. If any of the conditions above
apply to your child, please immediately contact your school nurse.
Student Information:
Name: ________________________________________________________________________________
First Middle Last
Goes By:
__________________ Sex:
_______ DOB: ____________ Grade
Level: _______
Address:
______________________________________________________________________________
Street
City
State Zip
Contact Information: (Mother, Father, Grandparents, etc. that can be
reached in case of sickness)
________________________________________
______________________________________
Name
Relationship
Name
Relationship
Home Phone: (___)______________________
Home Phone: (___)______________________
Work Phone: (___)______________________ Work Phone: (___)______________________
Cell Phone: (___)________________________ Cell Phone: (___)________________________
Email:_________________________________
Email:_________________________________
Student lives with: Both parents_____ Mother_____ Father______
Other_____
Name:______________________________Relationship:_________________________
Home Phone:_____________________Work
Phone:____________________Cell Phone:______________
In the event of a medical emergency, if a parent or
guardian cannot be reached, please contact:
(Provide a local contact if possible.)
Name:_____________________________Home
phone:________________Cell phone:_______________
Work
phone:__________________Relationship:_______________________
Name:_____________________________Home
phone:________________Cell phone:_______________
Work phone:_________________
Relationship:_______________________
Medical History: Check the
medical issues that apply to your child and describe on back.
___ADD/ADHD ___Anxiety/Panic Attack ___Asthma ___Autism
___Bee Sting Allergy ___Bleeding Disorder ___GI Problems ___Depression
___Diabetes ___Epi-Pen ___Hearing Problems ___Seizures
___Heart Condition ___Hyperventilation ___Migraines ___Latex Allergy
___Frequent Headaches ___Orthopedic Problems ___Vision Problems ___Peanut Allergy
___Other Severe Allergy ___Dye Allergy (Red #40) ___Cystic Fibrosis ___Cancer
___Kidney/Bladder Problems ___Sickle Cell Anemia ___High Blood Pressure ___Neuromuscular
___Other
____No
Known Medical Condition
Comment Section: Please describe in detail ALL medical conditions listed on previous
page including special instructions regarding precautions, warning signs,
emergency treatment, ability of student to advise regarding the condition,
etc. If you need more space for writing,
use a separate sheet of paper and attach it to this form.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medical History Continued:
Does your child wear glasses?
____Yes ____No Contact Lenses? ____Yes ____No
Name of Physician/Health Care
Provider: _________________________________ Phone # ____________
Name of Dentist:
_______________________________ Phone # ___________________
Is there anything else the
school nurse should know about your child? ______________________________
Medications:
Does your child take any
medications on a daily or an emergency basis?
____Yes ____No
If yes, list medication(s):
_______________________________________________________________
If yes, what condition is the
medication for? ________________________________________________
Must the medication be
administered at school? ____Yes ____No
(All medications administered at school must be
accompanied by an authorization form.
Please contact the school nurse for these forms or see the website.)
Initial _____I
give my consent for
Initial _____I give my permission for the school nurse to share the health information regarding my child with his/her teachers if necessary.
___________________________________ _______________________________
Parent/Guardian Parent/Guardian
If you have any questions or concerns, please call Melissa
Grimes, R.N., PCA School Nurse at 285-0077 (Ext. 261). If
your child is diagnosed with any medical condition during the school year,
please contact the school nurse.
Please Return This Form By The First Day Of School